The Health Network Service Area  

  1. The benefits offered by the plan (including applicable conditions and limitations), with information about how to access services whose eligibility and assessments are conducted outside of the plan;
  2. Any applicable cost sharing;
  3. The Health Network’s drug formulary;
  4. The provider network and how to access services (including pharmacies, addresses, and hours of operation);
  5. Out-of-network coverage (including pharmacies);
  6. Coverage of emergency services;
  7. Prior authorization and review rules;
  8. Grievances, organization and coverage determinations, and appeals (contains sufficient information about the types of grievances and appeals available, how to initiate the appeals and grievances, and how to obtain assistance with the appeal or grievance); Quality assurance policies and procedures;
  9. Disenrollment rights and responsibilities;
  10. Potential for contract termination;
  11. Medication therapy management program;
  12. Informing materials published in alternative formats (e.g., large print, Braille, audio CD);

Link to the electronic complaint form on www.caloptima.org